MEDICARE: MISS MIA LOREN SALAS COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	2023047363	MO

General Provider Information

NPI Number	:	1639932106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MIA LOREN SALAS COTA/L

Provider Business Mailing Address
First Line	:	1010 AVALON ST APT 11
Second Line	:
City	:	TRENTON
State	:	MO
Zip	:	64683-2697
Country	:	US
Telephone Number	:	660-988-7186
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 AVALON ST APT 11
Second Line	:
City	:	TRENTON
State	:	MO
Zip	:	64683-2697
Country	:	US
Telephone Number	:	660-988-7186
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2024
Last Update Date	:	02/06/2024

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